Provider Demographics
NPI:1336246305
Name:FULLER, LONNIE EDWARD JR (MD)
Entity Type:Individual
Prefix:DR
First Name:LONNIE
Middle Name:EDWARD
Last Name:FULLER
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:3501 SINCLAIR LN
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21213-2029
Mailing Address - Country:US
Mailing Address - Phone:410-732-8800
Mailing Address - Fax:410-534-2392
Practice Address - Street 1:3700 FLEET ST.
Practice Address - Street 2:SUITE 200
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21224
Practice Address - Country:US
Practice Address - Phone:410-558-4900
Practice Address - Fax:410-522-1475
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2015-11-05
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
PAMD041830L207R00000X
MDD73006207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001241798Medicaid
PA001241798Medicaid
PAE83655Medicare UPIN